Red cheeks to red cell aplasia: parvovirus B19 in a heart

transplant patient

Image ID: 61111

Authors: Sam Sadigh; Dale Frank

Category: Infectious Disease > Viruses > Parvovirus B19

Description: A 66-year-old man developed dizziness and fatigue 2 months after

orthotopic heart transplant for ischemic cardiomyopathy. His immunosuppressive
regimen included tacrolimus, mycophenolate mofetil, and prednisone. He was
found to be severely anemic (hemoglobin, 6.6 g/dL). Clinical studies excluded acute
blood loss or hemolysis. Reticulocyte count was 0.2%, and erythropoietin level was
750 mIU/mL (range, 3-19 mIU/mL). A bone marrow aspirate smear revealed large
atypical cells with prominent intranuclear inclusions and vacuolated cytoplasm
(panels A and B; original magnification ×100, Wright-Giemsa stain), which were
also evident on a hematoxylin and eosin stain of the aspirate clot (panel C; original
magnification ×40). Megakaryocytes and myeloid precursors were easily identified;
however, there was essentially no erythroid maturation. E-cadherin stain confirmed
that atypical cells were virally transformed erythroid precursors (panel D; original
magnification ×40). Serum parvovirus B19 polymerase chain reaction was positive.
Anti-parvoviral immunoglobulin M (IgM) and IgG titers were within normal
limits.Giant virally transformed proerythroblasts and erythroid maturation arrest are
classic findings of parvovirus B19–associated pure red cell aplasia. Although most
adults acquire lifelong immunity to parvovirus B19 from exposure in childhood,
reinfection can occur in the setting of immunocompromise, leading to prolonged
severe anemia. In retrospect, our patient had had contact with a granddaughter with
high fevers and red cheeks several weeks before his initial presentation. His
hemoglobin recovered after supportive transfusions and 5 days of IV
immunoglobulin. He remains well 2 years posttransplant.

AMERICAN SOCIETY OF HEMATOLOGY

2021 L Street NW, Suite 900, Washington, DC 20036 | Phone 202-776-0544 | Fax 202-776-0545

Copyright © 2020 American Society of Hematology

Copyright © 2020 American Society of Hematology. Copyright restrictions may apply.

Infectious mononucleosis

Image ID: 61130

Authors: Sadhika Sood;Girish Venkataraman

Category: Infectious Disease > Viruses > Epstein-Barr Virus > Mononucleosis
–peripheral blood

Description:
This patient is a 16-year-old female who presented with enlarged lymph nodes and
fever. A routine CBC performed with smear shows numerous large, atypical
lymphocytes showing reactive mononucleosis. The lymphocyte on the right has
abundant cytoplasm which is intensely basophilic and shows cytoplasmic bleb
formation. The variant lymphocyte in the centre has a classical so called “Ballerina
skirt” appearance with scalloped margins and indentations by the surrounding red
blood cells. The cytoplasm is vacuolated. Further testing demonstrated positive
monospot test confirming Infectious mononucleosis.

Copyright © 2020 American Society of Hematology. Copyright restrictions may apply.

Talaromyces marneffei and dysplastic neutrophils on blood smear

in newly diagnosed HIV

Image ID: 61213

AMERICAN SOCIETY OF HEMATOLOGY

2021 L Street NW, Suite 900, Washington, DC 20036 | Phone 202-776-0544 | Fax 202-776-0545

Copyright © 2020 American Society of Hematology

Authors: Jad Othman; Christina M. Brown

Category: Infectious Disease > Viruses > Human Immunodeficiency Syndrome

Description: A 23-year-old Thai man presented with lethargy, arthralgia, diarrhea,

fevers, and a papular rash. Past medical history was unremarkable. White cell
count was 4.5 × 10 9/L (neutrophils 2.6 × 10 9/L, lymphocytes 0.1 × 10 9/L),
hemoglobin 10 g/dL with mean corpuscular volume of 59 fL, and platelets 33 × 10
9/L. The peripheral blood film revealed small (2-5 m) round-to-ovoid yeast cells with
occasional central septa located predominantly within neutrophil cytoplasm (panels
A-C; original magnification ×1000, May-Grünwald Giemsa stain). Also noted were
striking neutrophilic dysplasia with large abnormal forms, binucleate cells (panel D;
original magnification ×1000, May-Grünwald Giemsa stain), and frequent small
nuclear fragments, some detached and others connected by a fine filament (panel
E; original magnification ×1000, May-Grünwald Giemsa stain). Red cells were
hypochromic and microcytic, with target cells consistent with known -thalassemia
trait.The patient was subsequently diagnosed with AIDS, with an HIV viral load of
282 137 copies/mL and CD4 count of 8 cells/µL. Advanced HIV infection can cause
marked dysplasia, with round nuclear fragments reported to be a specific feature.
Blood cultures grew Talaromyces marneffei (formerly Penicillium marneffei), a
dimorphic fungus that is an important opportunistic pathogen in southeast Asia
(panel F; original magnification ×1000, Gram stain; courtesy of R. Chan, Infectious
Diseases Department, Royal Prince Alfred Hospital, Sydney, Australia). With heavy
fungemia the organisms may be seen on the peripheral blood smear, which can
facilitate prompt diagnosis and treatment.

Copyright © 2020 American Society of Hematology. Copyright restrictions may apply.

Atypical lymphocytes in blood

AMERICAN SOCIETY OF HEMATOLOGY

2021 L Street NW, Suite 900, Washington, DC 20036 | Phone 202-776-0544 | Fax 202-776-0545

Copyright © 2020 American Society of Hematology

Image ID: 61989

Authors: Ira Miller, MD, PhD

Category: Infectious Disease > Viruses > Epstein-Barr Virus > Mononucleosis
–peripheral blood

Description:
The blood showed a high fraction of activated lymphocytes.

Copyright © 2020 American Society of Hematology. Copyright restrictions may apply.

AMERICAN SOCIETY OF HEMATOLOGY

2021 L Street NW, Suite 900, Washington, DC 20036 | Phone 202-776-0544 | Fax 202-776-0545

Copyright © 2020 American Society of Hematology